Key Guidelines and Evidence

There are several important guidelines that inform the diagnosis and management of pediatric bacterial meningitis:

Infectious Diseases Society of America (IDSA) Guidelines on Bacterial Meningitis

• Perform a lumbar puncture immediately unless signs of mass lesion or increased intracranial pressure. CT scan recommended prior to LP if focal neurological deficits present. (Level III)
• Initiate empiric antibiotic therapy within 1 hour of diagnosis, even before lumbar puncture is performed. Do not delay antibiotics for neuroimaging. (Level II)
• Empiric therapy should include vancomycin and a 3rd generation cephalosporin. (Level I)
• Dexamethasone should be given just prior to antibiotics in suspected pneumococcal meningitis. (Level I)
• Tailor antibiotics once culture results available. Consider local antibiotic resistance patterns. (Level III)
• Duration is 10-14 days for S. pneumoniae, 5-7 days for N. meningitidis, and 14-21 days for L. monocytogenes. (Level I – III depending on organism)
  • Tunkel AR, Hasbun R, Bhimraj A, et al. 2017 Infectious Diseases Society of America’s clinical practice guidelines for healthcare-associated ventricular shunt and intracranial pressure monitoring infections in adults and children. Clin Infect Dis. 2017;64(3):e34-e65. 

American Academy of Pediatrics (AAP) Guidelines on Bacterial Meningitis

• Perform lumbar puncture in any child with suspected meningitis unless signs of increased intracranial pressure. (Recommendation)
• Empiric antibiotic therapy should be initiated promptly in patients with suspected bacterial meningitis. (Recommendation)
• Routine imaging not needed before lumbar puncture unless specific neurologic abnormalities present. (Recommendation)
• Tailor therapy to culture results when available. Ensure appropriate antibiotic dosing to achieve bactericidal CSF concentrations. (Recommendation)
• Administer dexamethasone to infants older than 6 weeks with suspected pneumococcal meningitis. (Recommendation)
  • Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018. 

---

Landmark Clinical Trials:

Dexamethasone as Adjunctive Therapy in Bacterial Meningitis

• Multicenter, placebo-controlled trial in Europe evaluating dexamethasone in adults with bacterial meningitis
• 301 patients received dexamethasone vs. 297 patients received placebo along with antibiotics
• Dexamethasone associated with substantial benefit – RR of death 0.59 (95% CI 0.37–0.94) and unfavorable outcome 0.59 (95% CI 0.45-0.78)
• Benefit greatest in pneumococcal meningitis
  • de Gans J, van de Beek D, European Dexamethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med. 2002;347(20):1549-1556. 

Short Course Antibiotics for Bacterial Meningitis

• Multicenter noninferiority trial at five hospitals in Malawi and Nigeria
• 1116 children with meningitis randomized to 5 days vs 10 days of ceftriaxone
• 5 days of antibiotics found to be noninferior to 10 days (treatment failure 5.7% vs 6.8%)
• Concerns about generalizability to settings with more resources and different pathogens
  • Molyneux E, Nizami SQ, Saha S, et al. 5 versus 10 days of treatment with ceftriaxone for bacterial meningitis in children: a double-blind randomised equivalence study. Lancet. 2011;377(9780):1837-1845.